Exam 2 - EAQ

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How would we prevent an infection for a patient with tracheostomy?

chlorhexidine mouthwash decreases the bacteria in their mouth

What is atelectasis and what would we expect to hear?

collapsed lung; incomplete expansion of alveoli Diminished breath sounds

What is atelectasis?

collapsed of aveoli / lung

breathing exercises help which body part?

diaphragm

A COPD patients lung sounds

diminished breath sounds

Which action would a nurse take to decrease retained secretions in 13-year-old with an exacerbation of chronic bronchitis?

Increase fluid intake to at least 2000 mL/day.

Which observation indicates a desired response in a client with a chest tube due to a crushing chest injury?

Increased breath sounds

Which strategy will the nurse use to improve oxygenation in the client with ARDS

Prone positioning

Which would the nurse do to best facilitate communication postoperatively for a client who had a partial laryngectomy and tracheostomy?

Provide a means for the client to write

Which statement by the client leads the nurse to suspect the pleural effusion has returned after a thoracentesis?

"I get sharp, stabbing pain when I take a deep breath"

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

"Restraints are a last resort to prevent accidental extubation"

COPD patient can have how much oxygen?

1-2 liters Low concentration!

Which response by the nurse is appropriate for a client emphysema who is questioning why he or she has a barrel chest?

The air sacs in your lungs are no longer elastic, and this causes an increase in the lung size

What would we hear when a patient has pneumothorax?

absent breathe sounds

The nurse explains that the client is not to consume any food or drink after a bronchoscopy to decrease the risk for which complication?

aspiration

Which action would the nurse do when caring for a client with COPD and pleuritis?

assess for signs of pneumonia

Which would most concern the nurse if seen in a client during a current acute exacerbation of asthma?

Absence of wheezing this means that the airways have become so narrow that the client is unable to move any air.

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. Which summary represents this documentation of findings, crackles and rhonchi in the left lower lungs"?

An inaccurate interpretation

Which complication would the nurse monitor for in a client with chronic asthma?

Atelectasis

A patient needs to be restrained that had a tracheostomy?

Because they are attempting to pull out the tube

Which response is it a priority to monitor for after a throacentesis?

Blood!

A patient has pneumonia and taking antibiotics

Breathing exercises

Which long-term problem would the nurse monitor for in a client diagnosed with emphysema?

Carbon Dioxide retention

Which complications are most associated with chronic obstructive pulmonary disease (COPD)?

Cardiac problems

If there is excessive tiding for a chest tube what would we do?

Check for air leaks

What are signs and symptoms of Atelectasis?

Chest pain, dyspnea, Diminished breath sounds, crackles and even altered levels of consciousness caused hypoxia

What are the TB skin test classes?

Class 0: Did not give them a test Class 1: Skin Test Class 2: Chest Xray Class 3: Active TB

What would be our priority with tracheostomy?

Clear airway, with suctioning

What is our priority for someone with a tracheostomy?

Clear the airway

Which medication type will the nurse explain that includes fluticasone/salmeterol and mometasone furoate. Formoterol fumarate dihydrate while teaching about asthma medications?

Combination medication

what would our priority for a patient that just had a tracheostomy?

Communication! Provide the patient with pencil and paper

COPD patient has gained 5 lb of fluid, what is it called

Cor Pulmonale

Which type of lung sounds would the nurse expect to hear when caring for a client with heart failure exacerbation?

Crackles

If a patient has heart failure, what would we hear during auscultation and which side?

Crackling because the heart cannot get rid of the fluid. Left side!

What would we teach a patient after a chest tube is removed?

Deep breathing and incentive spirometer every hour

Which sign would the nurse expect to find in a client admitted with atelectasis?

Diminished breath sounds on auscultation

Which intervention is the priority when the client returns to the nursing unit following a right pneumonectomy.

Encourage deep breathing Helps keep the airway patent and prevents atelectasis of the remaing lung

After a bronchoscopy, which intervention is the most important

Ensure NPO until gag reflex returns

Which medication would be used to liquefy mucus for a client with a harsh, dry, cough due to bronchitis

Expectorant agent

Which medication would be used to liquefy mucus for a clien with a harsh dry cough due to bronchitis?

Expectorant agent Liquifies the mucus and helps them cough

What symptom would we report to the doctor when we have a patient has a cold or flu?

Fever

A patient that has inflamed pleura would have which type of sound?

Frictional rub

How do you position a patient with a pneumothorax?

High Fowler's position

Which race is most likely to develop pneumonia without vaccination?

Hispanic people

if a patient is having bronchitis, what is one thing we need to ensure they are doing?

Hydrate, with at least 2,000 mL of water daily.

You have a cold, but your doctor will not give you an antibiotic, because

It's a virus and cannot be cured that way

Which intervention would the nurse use to prevent aspiration in a client who underwent a partial laryngectomy?

Keep suction machine close during meals

Which is the priority in the immediate postoperative period for a laryngectomy?

Keep the trachea free of secretions

How should a patient with a tracheostomy be positioned?

Lateral/Fowlers because it helps the drainage of secretions HOB elevated

What substance will the home health nurse instruct a client to use after a laryngectomy to cleanse the stoma site?

Mild soap and water

Which substance will the home health nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Mild soap and water

What findings would the nurse expect when caring for a client with cor pulmonale?

Neck vein distension Lower extremity edema Right upper quandrant abdominal tenderness Elevated BNP levels

Which type of pressure will be reestablished when the chest tube and closed chest drainage system are effective?

Negative pressure in pleural space

Tuberulosis Symptoms include

Night sweats and Blood tinged sputum

Which clinical manifestations would be expected of a client with tuberculosis (TB)?

Night sweats and blood-tinged sputum

if a patient came in and they got pnemonia after?

Nosocomial pneumonia

Which health care providers prescription would the nurse question while caring for a client suffering from COPD

O2 per nasal cannula at 7 L/min

What position would we place a patient with emphysema

Orthepenic

If a patients chest tube is dislodged what would we do?

Place petroleum, cleanest available

What electrolyte would a patient when they take a diuretic

Potassium

Which mechanism represents why the client with COPD uses pursed-lip breathing?

Prolonged exhalation to decrease air trapping

Who would we notify when there is an "outbreak" of TB?

Public Health Department

What can sleep apnea cause?

Pulmonary edema

Which finding would the nurse expect when assessing a client with pleural effusion?

Reduced or absent breath sounds at the base of the lung

Who would the nurse consult with to meet the clients needs based on information below that was obtained from a client with COPD? -Dyspneic on exertion -Diminished Appetite -Uses oxygen all the time

Registered dietician

which complication is the nurse trying to prevent by encouraging a client to turn side to side and complete deep-breathing exercises after abdominal surgery?

Respiratory Acidosis

A patient with asthma is having ?

Respiratory Alkalosis

rheumatic fever (rheumatic heart disease)

Rheumatic fever - an acute inflammatory disease of the heart potentially involving all layers (endocardium, myocardium, and pericardium) Rheumatic heart disease - a chronic condition resulting from RF that is characterized by scarring and deformity of heart valves.

What sounds are heard when auscultating a COPD patient?

Rumbling and coarse Rhonchi

Which action would the nurse teach the client to do when teaching about nebulizer use?

Seal the lips tight around the mouthpiece and breathe in and out, taking slow, deep breaths.

A patient had thoracic surgery one week ago and are having pain while coughing, what would we educate the patient to do?

Split pillow!

Administering a shot (TB, Pneumonia), if they have a low immune system and have a possibility for infection

Stay with the patient, monitor to see if they have a reaction to the medication

which action would the nurse complete when caring for a client with tracheostomy?

Sterile gloves

What would the nurse include in a plan of care for a client who just had a total laryngectomy?

Suctioning

A patient with asthma sometimes get prescribed a serious of meds what must the nurse educate the patient to do ?

Take the combination of Beta Blockers and steroids

Which action performed by the client indicates a need for correction in a client with asthma who was just taught about self-management of long-acting medication?

Taking the medication when an asthma attack is triggered

If two adjacent ribs are broken into two or more parts, what would we see?

That the chest will not move equally, it will be a paradoxal movement

Which action will the nurse take first when the low flow alarm is persistently sounding on a client who is sedated and mechanically ventilated?

Ventilate manually and call for assistance

How would the nurse document a client who was intubated 3 days ago and has developed pneumonia

Ventilator-associated pneumonia

Where would we place a pulse ox

Warmest finger No nail polish and no acrylic If unable then ear

Why would we only give 1-2 liters of oxygen in a patient with COPD?

We still want the respiratory center to work

The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the patient problem of activity intolerance related to an imbalance between the oxygen supply and demand?

optimum rest

A bed bound patient can develop what?

pneumonia

What would someone be at risk for if they are immobilized?

pneumonia

Which action will the nurse take when noticing a client with chest trauma begins to experience dyspnea, tachycardia, restlessness, anxiety, decreased movement of chest wall and absent breath sounds on the affected side?

prepare for insertion of a chest tube

What breathing technique would you teach a COPD patient ?

pursed lip breathing

pneumonectomy is what?

removal of a lung

Which explanation is appropriate when a client with a spontaneous pneumothorax asks, why did they put this tube into my chest?

remove air from pleural space remove negative pressure

If a patient asks why they need to have a chest tube?

remove air from the pleural space

Which condition is the nurse attempting to prevent when encouraging a surgical client to turn from side to side and complete deep-breathing exercises?

respiratory acidosis and pneumonia (they have shallow breathing) Incentive spirometer Ambulate

What would we emphasize with a patient taking antibiotics?

take them until completion because our body becomes

What is an intervention to prevent the spread of TB?

use of an N-95 mask or HEPA


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